Share your favorite anesthesia tricks!

[aphistis]

So I'm sitting here typing this with my left mandible completely numb from the inferior alveolar & long buccal blocks I received tonight, and my upper right premolar area from the MSA. I had pretty good luck for my first time out, I thought--I got the MSA and long buccal on the first try, and the IANB on the second (my first try nabbed the lingual ).

One thing I noticed was that all the different faculty supervisors floating through the clinic all had their own individual tricks & preferences for getting the injections right. I imagine the same applies for the upperclassmen & practicing dentists here, so what better opportunity to share the wealth?
Does anybody have any favorite anesthetic techniques that aren't in the textbooks, but should be?

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[UNLV OMS GUNNABE]

Foramen magnum block is my favorite.

 

[aphistis]

Foramen magnum block is my favorite.

Do you administer that with a 2x4 in a dark alley?

 

[tx oms]

ALWAYS bend the needle.

NEVER waste time with a Gow-Gates.

Patients EXPECT the shot to hurt, not the procedure. Meet their expectations. Forget topicals, "painless injections" (no such thing), injecting one carpule over two hours, etc.

Throw away your 30gauge needles, your short needles, and your topical.

Maxillary quadrant anesthesia for non-surgical procedures can be obtained by inserting the needle into the maxillary unattached gingiva parallel to the plain of occlussion and laying down a line of anesthesia covering the necessary teeth.

The maxillary nerve block via the greater palantine canal or percutaneously via the infraorbital foramen are fun but I just don't trust any "maxillary block".

Be a man and stick the needle straight into the incisive papilla--don't puss out and walk the needle through the gingival embrasure little by little.

If the bottom lip is "fat" but the patient is complaining of pain, inject into the floor of the mouth adjacent to the tooth in question for a mylohyoid block, try a PDL injection, then forget it. They can come back when they want to behave like an adult.

If the IAN block fails three times, kick them to the curb. Once you get past the initial learning curve you're not going to miss that block after three tries. The patient is probably just too high strung for you to work on.

Mandibular block technique: 1/4 carpule for the lingual, 3/4 for the IAN. 1/3 carpule for the long buccal, remaining 2/3 added to the initial IAN. If the IAN doesn't numb after this, add two more carpules (give the 1st time to work before using the second) in different positions along the ramus. If that doesn't work, see the previous paragraph.

 

[unlvdmd]

ALWAYS bend the needle.

NEVER waste time with a Gow-Gates.

Patients EXPECT the shot to hurt, not the procedure. Meet their expectations. Forget topicals, "painless injections" (no such thing), injecting one carpule over two hours, etc.

Throw away your 30gauge needles, your short needles, and your topical.

Maxillary quadrant anesthesia for non-surgical procedures can be obtained by inserting the needle into the maxillary unattached gingiva parallel to the plain of occlussion and laying down a line of anesthesia covering the necessary teeth.

The maxillary nerve block via the greater palantine canal or percutaneously via the infraorbital foramen are fun but I just don't trust any "maxillary block".

Be a man and stick the needle straight into the incisive papilla--don't puss out and walk the needle through the gingival embrasure little by little.

If the bottom lip is "fat" but the patient is complaining of pain, inject into the floor of the mouth adjacent to the tooth in question for a mylohyoid block, try a PDL injection, then forget it. They can come back when they want to behave like an adult.

If the IAN block fails three times, kick them to the curb. Once you get past the initial learning curve you're not going to miss that block after three tries. The patient is probably just too high strung for you to work on.

Mandibular block technique: 1/4 carpule for the lingual, 3/4 for the IAN. 1/3 carpule for the long buccal, remaining 2/3 added to the initial IAN. If the IAN doesn't numb after this, add two more carpules (give the 1st time to work before using the second) in different positions along the ramus. If that doesn't work, see the previous paragraph.

Definatley an oral surgeon! You all are ruthless!

 

[toofache32]

I agree with every word Tx OMS said, this has been my experience also.

I have been doing a lot of complete V2 blocks via the greater palatine canal lately. Especially good for anterior maxillary pus that won't let you numb the infraorbital nerve. Just give about 1/3 carpule at the greater palatine nerve just like you always do. Give it about 30 seconds and then stick your needle back in and probe around until you drop in to the canal. In my experience, it's usually more lateral than you would think. Then slowly hub the needle and slowly inject the rest of the carpule (the needle has to be bent).

There's a great article called "How to Block & Tackle the Face" that you can look up on PubMed or whatever. I think it was in PRS a few years back. It's more for facial than dental procedures but it gives a different perspective on blocks.

 

[Extraction]

Listen to your oral surgery faculty's advice.... They pull teeth which requires profound anesthesia. Restorative work can be tolerated by many patients who aren't completely numb and don't always complain. Non-OMFS faculty who don't pull teeth forget this.

Both TX_OMF and toofache32 gave excellent advice. I'd add that I like to come from the opposite 2nd mandibular bicuspid on the IAN and hit the ramus then pull back 1mm and put the needle in a line bisecting the mandibular incisors and bury the 27L needle 2/3 of the way to the hub for the IAN. You can walk the needle back along the ramus if you have to... I very rarely miss. Ditch the topical, it just makes the patients salivate and want to spit.

If a patient isn't numb when you are extracting tooth out stab them with the 301 in the gingivae and see if they are numb. If not give more. If they are, consider a PDL, but they are probably just feeling pressure. In your private practice consider using carbocaine 1st, it supposedly burns less... Don't worry about blood pressure too much. According to Malamed, anything 180/110 or less is ok for emergency work. Also, It's better to give more epi and get them numb than extract a tooth without profound anesthesia. Patient's adrenals have alot more epi than our little carpules.

 

[gryffindor]

Ditch the topical, it just makes the patients salivate and want to spit.

I hate the topical, but it seems like the restorative patients expect the topical and need you to hold their hand through the "I'm afraid of needles even though I am a recovering heroin addict."

The patients I see who walk in on emergency and receive an extraction and are never seen again seem to be more tolerant of my not using topical. It's like they don't know topical exists so they don't know what they're missing.

However, the J. Morita company (makers of Apex Locators) gave us some topical samples the other day that are really really strong. The restorative patients haven't been feeling anything when I inject.

 

[simpledoc]

I have 2 ways to do the inf alvlr block.
the 1st (conventional) one which ive modified a little bit....palpate with the left thumb the deepest part of the coronoid notch, just before the ramus starts ascending and lingual to that region is yur bulls eye..shoot the needle from the opposite side bisecting the premolars...if everything goes perfect, then, after going 3/4th the length of the needle, you will feel that you have hit the lingula (hard bony feeling); aspirate now and then inject the "jesus juice"!!
after this, i give the long buccal nerve block and the gingival infiltration with the 2nd carpule, this way you get total co-operation from the patient.

the 2nd one is to hit the needle a little higher( even before the IAN enters the mandibular canal) approach the needle from the opposing premolar region and exactly bisect the pterygomandibular raphe and penetrate slightly lingual to this midpoint. This way you will feel the hard bone (ramus) and then inject.

what i do when things dont favor me after the 1st carpule failed (trust me, this is rare atleast for me)?
i will know for sure (even before the patient knows) that ive failed the block, if i feel I my needle did not hit the lingula (read the 1st technique above)
i then use my second carpule based on the 2nd technique and then use an additional carpule (septocaine preferably) to inject around the buccal and lingual gingiva. this gives the patient profound anesthesia and is predictable, atleast for me!

 

[DrJeff]

ALWAYS bend the needle.

NEVER waste time with a Gow-Gates.

Patients EXPECT the shot to hurt, not the procedure. Meet their expectations. Forget topicals, "painless injections" (no such thing), injecting one carpule over two hours, etc.

Throw away your 30gauge needles, your short needles, and your topical.

Maxillary quadrant anesthesia for non-surgical procedures can be obtained by inserting the needle into the maxillary unattached gingiva parallel to the plain of occlussion and laying down a line of anesthesia covering the necessary teeth.

The maxillary nerve block via the greater palantine canal or percutaneously via the infraorbital foramen are fun but I just don't trust any "maxillary block".

Be a man and stick the needle straight into the incisive papilla--don't puss out and walk the needle through the gingival embrasure little by little.

If the bottom lip is "fat" but the patient is complaining of pain, inject into the floor of the mouth adjacent to the tooth in question for a mylohyoid block, try a PDL injection, then forget it. They can come back when they want to behave like an adult.

If the IAN block fails three times, kick them to the curb. Once you get past the initial learning curve you're not going to miss that block after three tries. The patient is probably just too high strung for you to work on.

Mandibular block technique: 1/4 carpule for the lingual, 3/4 for the IAN. 1/3 carpule for the long buccal, remaining 2/3 added to the initial IAN. If the IAN doesn't numb after this, add two more carpules (give the 1st time to work before using the second) in different positions along the ramus. If that doesn't work, see the previous paragraph.

What's the diffrence between an oral surgeons injection technique and a good GP's???? About 30 seconds I have found from both personal experiences and from what many of my patients that I refer to my local O.S.'s that *in general* O.S.'s tend to be in a race when injecting that carpule of anesthetic Think about it, you're injecting almost 2ml of p.H. incompatible liquid into a space that's not large enough to comfortably take 2ml of liquid. The 2 second O.S. push of the anesthetic WILL create a serious burning sensation to most patients that will illicit a response. I've found over 1000's of injections that if to take ATLEAST 30 seconds to administer that carpule that you can give a very comfortable if not painless injection in most locations, and believe me, you're patients will greatly apprecite this, and they do tell their friends who then come and see you saying that "Mrs X told me that you gave her a PAINLESS shot!"

The other trick that I have for the IAB (given to me during my 2nd year of my GPR by one of the 1st year residents) is 1) as mentioned before, bend the needle (I go about 30 degrees or so using a short 30 guage), then use the classical "enter along the imaginary line from the ascending ramus to the oppsoite 2nd pre-molar approx 1cm above the occlussal table(blah, blah, blah)". The trick that I use is to find bone with the needle(medial surface of the ascending ramus) and then "walk the needle back" and off the posterior surface of the ramus. Once you've gone off the posterior surface of the ramus, come slightly back anterior onto the ramus again, aspirate and if no heme flashes into the carpule, inject the carpule (I'll do a full carpule for restorative and 2 if I'm doing an extraction or endo). I get over 95% of my IAB's this way

BTW, the most common area I've found where patient's will feel something even with positive lip and tongue anesthesia is over the Mesial roots of 19 and 30. So if I'm doing a class 5 in those areas, or entering a hot pulp chamber on one of those teeth, I'll often supplement my IAB with a mental nerve block or occasionally a PDL over the mesial root.

 

[tx oms]

palpate with the left thumb the deepest part of the coronoid notch, just before the ramus starts ascending and lingual to that region is yur bulls eye..shoot the needle from the opposite side bisecting the premolars

Don't inject with your fingers in the mouth. That's why God gave us retractors.

What's the diffrence between an oral surgeons injection technique and a good GP's????

An oral surgeon can't call anyone for help if he can't the patient numb?
Patients expect the shot to hurt. So, instead of being all metrosexual and caring, just worry about getting them numb. Patient's don't brag about your injections, they brag that nothing hurt after the shot.

I go about 30 degrees or so using a short 30 guage

Throw those away, then order more long 27 gauge.

BTW, the most common area I've found where patient's will feel something even with positive lip and tongue anesthesia is over the Mesial roots of 19 and 30. So if I'm doing a class 5 in those areas, or entering a hot pulp chamber on one of those teeth, I'll often supplement my IAB with a mental nerve block

How does a mental nerve block help the mesial root of a first molar?

 

[DrJeff]

An oral surgeon can't call anyone for help if he can't the patient numb?
Patients expect the shot to hurt. So, instead of being all metrosexual and caring, just worry about getting them numb. Patient's don't brag about your injections, they brag that nothing hurt after the shot.

Last 6 years of practice, I've had a grand total of 2 patients that I haven't been able to get numb. Take your time while administering anesthesia, you might be suprised in the future when your out in private practice how many GP's will STOP sending you referrals if they're hearing that your rougher and more painfull than the patient's GP is. The real scary thing for you is that we as GP's often won't tell you why we're not sending folks your way if we get tired of hearing our patients gripe about how you treat them, and I'm not trying to sound arrogant here, but if we as GP's aren't sending you patients, your bills aren't getting paid.

case in point, I've got 2 O.S.'s in my immediate geographic area. Last year I referred out 83 wisdom tooth cases (as you know your big $$ producing bread and butter cases), one of my local O.S.'s has started getting real rough(over 1/2rd of my patients gripe about him when they see me at their next visit) and has started to do things like change my treatment plans for teeth to be exo's/saved without consulting me. So now when I'm referring all those 18-25 yr old 4 wizzy IV cases instead of splitting them 50/50 between the 2 O.S.'s its now about 95/5 which at the rates that he charges for 4 wizzy's and sedation is about a $60,000/year hit!

[QUOTE}Throw those away, then order more long 27 gauge.[/QUOTE]

No way, I think that between me and my partner we might have a box of 27 longs in the office, but I'm not sure. It's all about the comfort factor again, and their just aren't too many places that you can't reach with a 30 short, plus the narrower diameter also helps keep the injection flow rate at a slower more comfortable rate!

How does a mental nerve block help the mesial root of a first molar?

I'm with you on this one too. Realizing that anatomicaly it doesn't make any sense, and if I wasn't for the fact that I've literally seen it work 40 or 50 times over the years without adding any supplemental IAB or PDL??? The way I learned this one was from one of my GPR attendings, a 40+ year clinician, Pankey Trained, more hours of career CE than 20 normal dentists combined, etc, etc, etc. I was prepping #30 for a crown, and had 85% of the prep done with the patient completely comfortable. Everytime the diamond went around the MB line angle the patient would jump out of the chair. Kept adding more anesthesia(IAB, PDL, straight infiltration), patient would still jump. Went and got the attending, 10 min later he sat at the chair, picked up the handpiece, and the patient jumped when he hit the MB line angle. He administered 1/2 carpule of 2% lido via a mental block, and as soon as ne recapped the needle and picked up the handpiece, the patient was comfortable. His explanation is that abberrant anatomy of the IA nerve can have fibers back tracking to the mesial root of lower 1st molars after the IA exits the mental foramen.

whether or not this is the true explanation, I'm not sure. But after seeing it work time and time again in this specific clinical situation, it works in my hands

 

[unlvdmd]

From inital experience, the reason OMS can inject like that is because they can. I mean, they don't have to answer to those people every 6 months. Its like an assembly line of extractions in some offices and they never see the patient again. But the GP's have a reputation to keep and business is gained/lost based upon that ONE PROCEDURE!

 

[picklebaron]

*

 

[DrJeff]

From inital experience, the reason OMS can inject like that is because they can. I mean, they don't have to answer to those people every 6 months. Its like an assembly line of extractions in some offices and they never see the patient again. But the GP's have a reputation to keep and business is gained/lost based upon that ONE PROCEDURE!

Remember though while the OMFS may only see that patient once, they have family/friends that they tell, and more importantly, they tell the GP about the experience. Plus if we actually care to, taking the time to give a comfortable/painless injection (where anatomically possible) can and does go a long way to dispell the myth that we're just painmongers. And if you can help dispell that myth to many of your patients you'll be amazed at how of those patients will tell their friends and how many of them will come and see you(read as GREAT, FREE advertising! )

 

[unlvdmd]

Remember though while the OMFS may only see that patient once, they have family/friends that they tell, and more importantly, they tell the GP about the experience. Plus if we actually care to, taking the time to give a comfortable/painless injection (where anatomically possible) can and does go a long way to dispell the myth that we're just painmongers. And if you can help dispell that myth to many of your patients you'll be amazed at how of those patients will tell their friends and how many of them will come and see you(read as GREAT, FREE advertising! )

Couldn't agree more. The first thing people ask about your dentinst: Do they give good shots?
If it was a good experience it is usually the first thing people brag about to their friends(not even their new set of veneers)!!! VERY true.

 

[DcS]

I agree with Dr. Jeff and the technique I use is pretty much exactly as he described. The injection is probably the most anxiety-ridden part for most patients. The initial stick isn't really what hurts, it's more the pressure buildup from the speed of injection. I may take 20-30 secs to drop the carpule but my patients have told me it makes a huge difference. Remember, besides highly esthetic cases patient's don't know good dentistry. They know pain and the strength of it's motivation can be ridiculous. For a GPs perspective it's a much better move to take care injecting and having patients rave about it when you are done. It's one of the first things they'll say to a future patient referral.

I think a lot of it also depends on your philosophy of your patients. If you think of them of a walking, talking dollar bill then yeah go ahead and give a rats ass about their experience in your office. If you really understand you have a human being in your chair and can learn to appreciate things from their point of view you're much more likely to take your time.

For technique as I said Dr. Jeff nailed it. I landmark as he did and actually like hitting bone early because I can reposition. It gives a steady landmark versus hanging around in soft tissue with no way to gauge your location. With that technique in 2 years of clinics I have had 1 failure in an IAB (due to anatomical difference I have to do Gow-Gates on her), much lower than the 15-20% quoted in Malamed.

 

[tx oms]

The only part of the injection that matter is the final result: did you obtain profound anesthesia? Let's not wring our hands about painless injections. My patients like me. I don't win their trust through an injection; rather, through relating to them. They're like children, if you fuss over them everytime they throw a temper tantrum at Toys 'R Us they keep doing it. If you talk to them like adults and treat them professionally they act like adults.

 

[north2southOMFS]

I've found over 1000's of injections that if to take ATLEAST 30 seconds to administer that carpule that you can give a very comfortable if not painless injection

1000 injections x 30sec./injection = 30000 sec x 1min/60sec = 500min x 1hour/60min = 8.34hours


You lost at least 8.34 hours of your life just pushing a plunger.

 

[aphistis]

1000 injections x 30sec./injection = 30000 sec x 1min/60sec = 500min x 1hour/60min = 8.34hours


You lost at least 8.34 hours of your life just pushing a plunger.

Out of the 289080 hours (plus however long since his birthday) he's been alive, that comes out to 0.002% of his life. Given his career performance thus far, I'd say he's getting a pretty good return on investment.

 

[DrJeff]

Out of the 289080 hours (plus however long since his birthday) he's been alive, that comes out to 0.002% of his life. Given his career performance thus far, I'd say he's getting a pretty good return on investment.

Thanks Bill. Another way to look at it is out of those 1000 injections (figure that will be around 750 patients), if just 10% of them tell their friends how painless an injection I give, thats 75 new patients in my chair and on average a new adult patient will have approximately $2500 worth of work done in their first 18 months in my office (that's looking back my average production per new patient per 18 months over the last 5 years). That equals $18750 in additional production or when averaged over that 8.34 hours of my life, I'm billing just under $2500 per each of those 8.34 additional hours that I'm spending giving a slow, painless injection. Pretty good use of my time in my book!

 

[ItsGavinC]

Pretty good use of my time in my book!

Even better when you figure our math is based on 1000 injections, and certainly you've delivered more than that in your career.

 

[omfsres]

Even better when you figure our math is based on 1000 injections, and certainly you've delivered more than that in your career.

Everyone is forgetting one important thing about the OMS injection... the vast majority of patients are under general anesthesi or sedated during their injections. So they are either too out of it to care/notice, or they just won't be able to remember it. That's why we have the luxury not to be concerned with a painless injection.

 

[aphistis]

Everyone is forgetting one important thing about the OMS injection... the vast majority of patients are under general anesthesi or sedated during their injections. So they are either too out of it to care/notice, or they just won't be able to remember it. That's why we have the luxury not to be concerned with a painless injection.

Right, but likewise you're forgetting that most GP patients *aren't*.

Worthwhile point, though. Maybe the treatment circumstances are just too different for GP's & OMS' to find much common ground.

 

[tx oms]

Who taught your dental school anesthesia class?

 

[aphistis]

Who taught your dental school anesthesia class?

Our instructor is Dr. Klise, but we're currently taking the course. Why?

 

[tx oms]

Our instructor is Dr. Klise, but we're currently taking the course. Why?

Not you personally. Just pointing out that most courses are taught by oral surgeons. Wonder why?

Incidentally, my wife and I had dinner with a med school classmates and his wife last night. He asked me some questions about dentistry and then mentioned how much he hates getting shots in his mouth. He then volunteered he doesn't like it when dentists brag about their "painless injections" b/c he believes their is no such thing. He even told me he felt like they were lying to him.

All you guys that take pride in "painless injections" might want to start taking pride in your work and painless procedures. Don't let the focus of "painless anesthesia" keep you from using enough anesthesia appropriately.

 

[DrJeff]

Not you personally. Just pointing out that most courses are taught by oral surgeons. Wonder why?

Incidentally, my wife and I had dinner with a med school classmates and his wife last night. He asked me some questions about dentistry and then mentioned how much he hates getting shots in his mouth. He then volunteered he doesn't like it when dentists brag about their "painless injections" b/c he believes their is no such thing. He even told me he felt like they were lying to him.

All you guys that take pride in "painless injections" might want to start taking pride in your work and painless procedures. Don't let the focus of "painless anesthesia" keep you from using enough anesthesia appropriately.

It's really tough to believe that you can't give a "painless" injection when I hear patients atleast 2 or 3 times a day comment/ask me "when are you going to put the novacain in?" or "did you do it yet?" after have I already adimistered the entire carpule and recapped the needle.

I also view this part, the concept of not only profound, but also comfortable anesthesia as just the 1st step of the quality experience I look to provide to each and ecery patient. What i also STRONGLY believe is that if I can deliver that painless injection to the patient that they will then be much more relaxed when it's time to start whatever procedure I'm doing on them since for the vast majority of patients will say that the most "anxiuos" part of the visit for them is the injection and if you can EXCEED their expectations with a painless injection than they are much more relaxed for the rest of the visit and it is easier for you to work on them. While I'm not going to start having a massage therapist/aromatherapy/warm parafin soaks for the hands at my office anytime soon, this is one of the key concepts why "spa dentistry" works off of, get your patients relaxed and keep them relaxed and they're much easier to work on.

 

[tx oms]

While I'm not going to start having a massage therapist/aromatherapy/warm parafin soaks for the hands at my office anytime soon, this is one of the key concepts why "spa dentistry" works off of, get your patients relaxed and keep them relaxed and they're much easier to work on.

Fair enough. Thank you for not selling out.

 

[Extraction]

So all your palatal injections are painless???

 

[DrJeff]

So all your palatal injections are painless???

If you look on this thread, you'll see that I've never said ALL of my injections are painless Frankly during the times that I give palatals (endos, exos, and crown preps where I have to go subgingival on the lingual), I tell my patients that they're going to feel a pinch during the palatal, and then go on to justify why I'm doing it with the following statement, "this will be the difference between you being 98% numb and being 110% numb, and I'd rather you have a little pinch now than a big ouch later" Then I do the standard palatal technique where I'll apply pressure with the handle of my mirror or the back end of a topical stick and then inject the anesthetic.

True story about a palatal I gave once. It was during my GPR, and my best friend who is now a OMFS practicing in Maine, was doing one of his rotations at the hospital that my GPR was at. He was having some cold sensitivity on #15 when we'd go out for beers(any cold beer sensitivity justifies a MAJOR dental emergency in my book ), so he came to the clinic, we took a PA and he had some recurrent decay around an old amalgam on #15 OL. So I pumped a carpule of 2% lido into him via buccal infiltration and he says to me "I want a palatal just to see what all my patients whine about" (still to this day he's the 1st and only patient I've ever had requesting a palatal ). So I gave him one and after that I hit him with a greater palantine (again for his own personal edification - I drew the line when he asked for a V2). After giving the assortment of palatal injections, he says to me (drooping left lip/eye lid and all), "if that's what a palatal feels like my patients are wusses!"

 

[Fullosseousflap]

Articaine/Septocaine and Inject slowly.

 

[ItsGavinC]

Bumping for further discussion.

 

[ItsGavinC]

Who taught your dental school anesthesia class?

Stan Malamed for us at Arizona, although to be fair we followed up with an OMS guy.

And I'm bumping this again for more posts (I know you guys have more in ya!).

 

[Battlesign]

NO IANB, go with the, Gow Gates works every time. All in one shot. No long buccal, no lingual, get them all in one shot.

Want to avoid giving a palatal injection. Bend your needle, 27S, at a 45 degree angle and give a high PSA, slide around the Mx tuberosity, your right next to the pterygomaxillary fissure, inject a full carp. I like to use articaine, but lidocaine works as well. I have had great success with this.

I don't know the proper name for this technique. I call it the high PSA V2.
Again all in one shot injection.

 

[dentheartthrob]

When i started my clincal requirements last sem for EXO, My first question would be "Does it feel numb yet," followed by "Can you feel any pain," to eventually, "Can you handle it" hehehe.... A trick(i dont really think its a trick) in anesthezing i think that works wonder is just to show or atleast make visible the syringe along with the needle attatched to the patient.

 

[kerrydds06]

A trick(i dont really think its a trick) in anesthezing i think that works wonder is just to show or atleast make visible the syringe along with the needle attatched to the patient.

Try that on you Pedo rotation!

I like the magic approach esp for kids and phobes. I poke them with the topical coated cotton tip (the nasty taste distracts them and they get used to pressure and me doing "something" to their gums) and I make sure they DO see me using a cotton tip to poke them, the i do a switcharoo, make sure they DONT see the needle coming ,give the anes and when i'm done, wave the needle before them as i go to cap it. Sit back and watch the confusion on their faces with a smirk as i know what they are thinking, "did he just give me a shot?" as they start to "tingle".

BTW i drop the carpule in a cup o warm water (carpule warmer is one of my first purchases when i graduate) for a couple of minutes. Try infiltrating yourself with cold and then warm solution and then critize it!

The best way to test techniques that are harmless is on yourself! Have you ever tasted viscostat? or sat in your own dental chair and see how nasty theshield of the reflector is.